DON T WAIT TO SOUND THE ALARM

Transcription

1 Lifesaving treatment for chemotherapy toxicity is just a call away DON T WAIT TO SOUND THE ALARM Alarming reactions early in your 5-FU or capecitabine treatment may signal a dangerous toxic reaction This brochure will teach you How to recognize the signs of a severe or life-threatening reaction What to do if you think you may be having a reaction The benefits of treating toxicity fast with Vistogard (uridine triacetate)*, the only antidote to 5-FU or capecitabine toxicity *A pyrimidine analog. 5-FU=5-fluorouracil. What is VISTOGARD? VISTOGARD is a prescription medicine used for the emergency treatment of adult and pediatric patients: following a known fluorouracil or capecitabine overdose even if there are no symptoms present, or who show signs of toxicity within 96 hours following the end of fluorouracil or capecitabine administration. Who should not be treated with VISTOGARD? You should not be given VISTOGARD for treatment of adverse reactions with fluorouracil or capecitabine if they do not exist because it may diminish the efficacy of these drugs. The safety and efficacy of VISTOGARD started more than 96 hours after the end of fluorouracil or capecitabine treatment has not been established. Please see Important Safety Information on pages 2 and 6. One call could save your life.

2 If you receive 5-FU or capecitabine, you may be at risk for severe or life-threatening toxicity 5-FU (5-fluorouracil) and capecitabine (Xeloda ) may be given alone or in combination treatment regimens such as these 1,2 *: FOLFOX CapeOx FOLFIRI XELOX FLOX * This is not a complete list of chemotherapy combinations that include 5-FU or capecitabine. If you re unsure if your treatment regimen includes 5-FU or capecitabine, ask your cancer care team. Thousands of patients are treated with 5-FU or capecitabine, trusted chemotherapies with a history of success 3-7 Recognize the signs of a severe or life-threatening reaction Signs of a toxic reaction to chemotherapy can be mistaken for normal side effects 6,8-10 Normal side effects usually occur after finishing 5-FU infusion or capecitabine dosing, are not alarming, and can be alleviated by medicine Dangerous toxic reactions that require immediate attention can occur during the first or second round of 5-FU infusion or capecitabine dosing, and side effects quickly become severe 5-FU and capecitabine are widely used chemotherapy treatments, and most patients experience mild-to-moderate side effects About 10% of patients receiving 5-FU suffer from a toxic reaction In less than 1% of patients, 5-FU toxicity can be fatal Important Safety Information Common side effects of VISTOGARD include: vomiting, nausea, and diarrhea. These are not all the possible side effects of VISTOGARD. Call your doctor for medical advice about side effects or you may report side effects to the FDA at FDA Remember to tell your doctor about all of the medicines that you take. Normal chemotherapy side effects Mucositis mild (painful sores in the mouth and throat) Nausea mild to moderate Vomiting mild to moderate Diarrhea mild to moderate Hand-and-foot syndrome (capecitabine) (redness and mild tenderness on palms of hands and on soles of feet) Additional normal side effects include: Sensitivity to light Hair thinning or loss Nail changes Darkening of the skin Signs of 5-FU or capecitabine toxicity Mucositis severe (difficulty in eating, drinking, swallowing, or performing activities) Nausea severe (inability to eat or drink) Vomiting severe (vomiting 6 times or more per day) Diarrhea severe (diarrhea 7 times or more per day) Hand-and-foot syndrome (capecitabine) severe (pain, blisters, bleeding, and peeling that make performing daily activities difficult) Additional signs of toxicity include: Heart problems (chest pain, heart attack, irregular heart beats, heart failure) Brain and nervous system problems (dizziness, confusion, lack of coordination, seizure, coma) Loss of bowel or bladder control CapeOX=capecitabine/oxaliplatin; FLOX=fluorouracil/leucovorin/oxaliplatin; FOLFIRI=5-FU/LV/ irinotecan; FOLFOX=5-FU/LV/oxaliplatin; XELOX=capecitabine/oxaliplatin. 2 Please see Important Safety Information on page 6.

3 Time is of the essence: Act fast to stop toxicity in its tracks Immediately tell your cancer care team about any toxic symptoms so they have time to begin treatment with Vistogard Severe or life-threatening toxic reactions can occur during or after your first or second treatment with 5-FU or capecitabine 6 If treatment with Vistogard starts as soon as possible after chemotherapy ends, there is a better chance of stopping the toxic reaction 11 Don t wait to communicate During chemotherapy or within 4 days after it ends: Vistogard (uridine triacetate) fights toxicity so you can continue fighting your cancer Vistogard is the first and only antidote to treat 5-FU or capecitabine toxicity With Vistogard, survival is 96 % * Before Vistogard, survival was 16 % 130 of 135 (96%) patients in clinical trials survived severe 5-FU or capecitabine toxicity 11 98% of patients treated survived when Vistogard was given within 96 hours of ending their treatment 11 One-third of study patients continued chemotherapy within a month after treatment with Vistogard 12 WATCH FOR SIGNS ARE THEY SEVERE? MAKE THE CALL! Even if you re unsure, trust your instincts. Your cancer care team relies on you to keep them informed. References: 1. XELOX. National Cancer Institute website. treatment/drugs/xelox. Accessed April 11, Rose, LJ. Colon cancer treatment protocols. Medscape website. Updated March 28, Accessed April 11, Rodriguez RU. Public teleconference regarding licensing and collaborative research opportunities for: methods and compositions relating to detecting dihydropyrimidine dehydrogenase (DPD). Federal Register. 2008;73(129): E pdf. Accessed April 11, Cen P, Tetzlaff ED, Ajani JA. Contribution of capecitabine for therapy of patients with gastroesophageal cancer: an update of recent phase III results. Ther Clin Risk Manag. 2008;4(1): Capecitabine (Xeloda). Cancer Research UK website. org/about-cancer/cancers-in-general/treatment/cancer-drugs/capecitabine. Accessed April 11, Data on file, Wellstat Therapeutics 7. Amstutz U, Froehlich TK, Largiadèr CR. Dihydropyrimidine dehydrogenase gene as a major predictor of severe 5-fluorouracil toxicity. Pharmacogenomics. 2011; 12(9): Fluorouracil. Chemocare website. drug-info/fluorouracil.aspx. Accessed April 11, Hand-Foot Syndrome or Palmar-Plantar Erythrodysesthesia. Cancer.net website. hand-foot-syndrome-or-palmar-plantar-erythrodysesthesia. Accessed April 11, US Department of Health and Human Services. Common terminology criteria for adverse events (CTCAE). Published May 28, Updated June 14, Accessed April 11, Ison G, Beaver J, McGuinn DW Jr, et al. FDA approval: uridine triacetate for the treatment of patients following fluorouracil or capecitabine overdose or exhibiting early-onset severe toxicities following administration of these drugs. Clin Cancer Res. 2016;22(18): Vistogard [prescribing information]. Rockville, MD; Wellstat Therapeutics; *Survival was 96% among all patients treated with Vistogard for either early-onset severe toxicity or overdose % survival was shown in historical case reports of 5-FU overdose 12 Vistogard is proven safe and tolerable for patients 12 The most common side effects from Vistogard use in 135 patients enrolled in clinical studies were: Vomiting (10% of patients) Nausea (5% of patients) Diarrhea (3% of patients) The effects of Vistogard don t depend on a patient s gender or age Of the 135 patients in clinical studies with Vistogard, 30% were 65 years of age or older, and 11% were 75 years of age or older In the clinical studies, one patient receiving Vistogard had serious nausea and vomiting Two patients (1.4% of those in the clinical trials) discontinued Vistogard due to side effects related to treatment 4 Please see Important Safety Information on pages 2 and 6.

4 Remember to tell your cancer care team immediately if you experience 6,10 : Painful mouth sores that make it difficult to eat or drink Severe diarrhea 7 times or more per day Vomiting 6 times or more per day Confusion or dizziness Blisters, peeling, and bleeding on the hands and/or feet Chest pain or irregular heart beats Vistogard, the only antidote to 5-FU or capecitabine toxicity, fights toxicity so you can continue fighting your cancer 96% of patients in studies survived 5-FU or capecitabine early-onset severe toxicity or overdose after receiving Vistogard 12 98% of patients survived when Vistogard was given within 96 hours of ending their 5-FU or capecitabine treatment 11 Please visit VISTOGARD.com for more information. What is VISTOGARD? VISTOGARD is a prescription medicine used for the emergency treatment of adult and pediatric patients: following a known fluorouracil or capecitabine overdose even if there are no symptoms present, or who show signs of toxicity within 96 hours following the end of fluorouracil or capecitabine administration. Who should not be treated with VISTOGARD? You should not be given VISTOGARD for treatment of adverse reactions with fluorouracil or capecitabine if they do not exist because it may diminish the efficacy of these drugs. The safety and efficacy of VISTOGARD started more than 96 hours after the end of fluorouracil or capecitabine treatment has not been established. Important Safety Information Common side effects of VISTOGARD include: vomiting, nausea, and diarrhea. These are not all the possible side effects of VISTOGARD. Call your doctor for medical advice about side effects or you may report side effects to the FDA at FDA Remember to tell your doctor about all of the medicines that you take. Please see Important Safety Information on page , Wellstat Therapeutics Corporation. All rights reserved. BC VISTOGARD and the Vistogard logo are trademarks of Wellstat Therapeutics Corporation. The Wellstat logo is a registered trademark of Wellstat Therapeutics Corporation.

5 HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use VISTOGARD safely and effectively. See full prescribing information for VISTOGARD. VISTOGARD (uridine triacetate) oral granules Initial U.S. Approval: 2015 INDICATIONS AND USAGE VISTOGARD is a pyrimidine analog indicated for the emergency treatment of adult and pediatric patients: following a fluorouracil or capecitabine overdose regardless of the presence of symptoms, or who exhibit early-onset, severe or life-threatening toxicity affecting the cardiac or central nervous system, and/or earlyonset, unusually severe adverse reactions (e.g., gastrointestinal toxicity and/or neutropenia) within 96 hours following the end of fluorouracil or capecitabine administration. (1) Limitations of use: VISTOGARD is not recommended for the non-emergent treatment of adverse reactions associated with fluorouracil or capecitabine because it may diminish the efficacy of these drugs. (1) The safety and efficacy of VISTOGARD initiated more than 96 hours following the end of fluorouracil or capecitabine administration have not been established. (1) DOSAGE AND ADMINISTRATION Recommended Dosage Adults: 10 grams (1 packet) orally every 6 hours for 20 doses, without regard to meals. (2.1) Pediatric: 6.2 grams/m 2 of body surface area (not to exceed 10 grams per dose) orally every 6 hours for 20 doses, without regard to meals. See the full prescribing information for body surface area-based dosing. (2.1) Preparation and Administration Pediatric: Measure the dose using either a scale accurate to at FULL PRESCRIBING INFORMATION: CONTENTS* 1 INDICATIONS AND USAGE 2 DOSAGE AND ADMINISTRATION 2.1 Recommended Dosage 2.2 Preparation and Administration 3 DOSAGE FORMS AND STRENGTHS 4 CONTRAINDICATIONS 5 WARNINGS AND PRECAUTIONS 6 ADVERSE REACTIONS 6.1 Clinical Trials Experience 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.2 Lactation 8.4 Pediatric Use 8.5 Geriatric Use least 0.1 gram, or a graduated teaspoon accurate to ¼ teaspoon. (2.1) Mix each VISTOGARD dose with 3 to 4 ounces of soft foods such as applesauce, pudding or yogurt and ingest within 30 minutes of mixing. Do not chew the VISTOGARD granules. Drink at least 4 ounces of water. (2.2) If a patient vomits within 2 hours of taking a dose of VISTOGARD, initiate another complete dose as soon as possible after the vomiting episode. Administer the next dose at the regularly scheduled time. (2.2) If a patient misses a dose at the scheduled time, administer that dose of VISTOGARD as soon as possible. Administer the next dose at the regularly scheduled time. (2.2) Administer VISTOGARD via a nasogastric tube (NG tube) or gastrostomy tube (G-Tube) when necessary (e.g., severe mucositis or coma). (2.2) DOSAGE FORMS AND STRENGTHS Oral granules: 10 gram packets (3) None. (4) None. (5) CONTRAINDICATIONS WARNINGS AND PRECAUTIONS ADVERSE REACTIONS Adverse reactions occurring in >2% of patients receiving VISTOGARD included vomiting, nausea, and diarrhea. (6) To report SUSPECTED ADVERSE REACTIONS, contact Wellstat Therapeutics Corporation at ( ) or FDA at FDA-1088 or See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling 11 DESCRIPTION 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action 12.3 Pharmacokinetics 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 13.2 Animal Toxicology and/or Pharmacology 14 CLINICAL STUDIES 16 HOW SUPPLIED/STORAGE AND HANDLING 17 PATIENT COUNSELING INFORMATION * Sections or subsections omitted from the full prescribing information are not listed. Revised: 2/2017

6 FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE VISTOGARD is indicated for the emergency treatment of adult and pediatric patients: following a fluorouracil or capecitabine overdose regardless of the presence of symptoms, or who exhibit early-onset, severe or life-threatening toxicity affecting the cardiac or central nervous system, and/or early-onset, unusually severe adverse reactions (e.g., gastrointestinal toxicity and/or neutropenia) within 96 hours following the end of fluorouracil or capecitabine administration. Limitations of Use VISTOGARD is not recommended for the non-emergent treatment of adverse reactions associated with fluorouracil or capecitabine because it may diminish the efficacy of these drugs. The safety and efficacy of VISTOGARD initiated more than 96 hours following the end of fluorouracil or capecitabine administration have not been established. 2 DOSAGE AND ADMINISTRATION 2.1 Recommended Dosage Adults: 10 grams (1 packet) orally every 6 hours for 20 doses, without regard to meals. Pediatric: 6.2 grams/m 2 of body surface area (not to exceed 10 grams per dose) orally every 6 hours for 20 doses, without regard to meals. The VISTOGARD dose to be administered at 6.2 grams/m 2 is presented in Table 1. Measure the dose using either a scale accurate to at least 0.1 gram, or a graduated teaspoon accurate to ¼ teaspoon. Discard any unused portion of granules. Do not use granules left in the open packet for subsequent dosing. Table 1 VISTOGARD Pediatric Dose Based on Body Surface Area (m 2 ) Patient Body Surface Area Table 1 VISTOGARD 6.2 grams/m 2 /dose (m 2 ) Dose in Grams Dose in Graduated Teaspoons 0.34 to to to to ¼ 0.56 to to ½ 0.67 to to ¾ 0.78 to to to to ¼ 1.00 to to ½ 1.11 to to ¾ 1.22 to to to to ¼ 1.44 and above * full packet * Dose by body surface area category in this table was rounded to achieve the approximate dose. Each dose is administered every 6 hours for 20 doses. * May use 1 entire 10 g packet without weighing or measuring. Do not exceed 10 grams/dose. 2

7 Administer VISTOGARD as soon as possible after an overdose or early-onset toxicity within 96 hours following the end of fluorouracil or capecitabine administration. Administer full course of VISTOGARD (20 doses) as directed. 2.2 Preparation and Administration Mix each VISTOGARD dose with 3 to 4 ounces of soft foods such as applesauce, pudding or yogurt and ingest within 30 minutes. Do not chew the VISTOGARD granules. Drink at least 4 ounces of water. If a patient vomits within 2 hours of taking a dose of VISTOGARD, initiate another complete dose as soon as possible after the vomiting episode. Administer the next dose at the regularly scheduled time. If a patient misses a dose at the scheduled time, administer that dose of VISTOGARD as soon as possible. Administer the next dose at the regularly scheduled time. Administer VISTOGARD via a nasogastric tube (NG tube) or gastrostomy tube (G-Tube) when necessary (eg, severe mucositis or coma). Follow the instructions below for each dose administration: 1. Prepare approximately 4 fluid ounces (about 100 ml) of a food starch-based thickening product in water and stir briskly until the thickener has dissolved. 2. Crush the contents of one full 10 gram packet of VISTOGARD granules to a fine powder. 3. Add the crushed VISTOGARD granules to 4 ounces (about 100 ml) of the reconstituted food starch-based thickening product. For pediatric patients receiving less than 10 grams, prepare the mixture at a ratio of no greater than 1 gram per 10 ml of reconstituted food starch-based thickening product and mix thoroughly. 4. After administration of the mixture using the NG tube or G-Tube, flush the tube with water. 3 DOSAGE FORMS AND STRENGTHS Oral granules: 10 grams of orange-flavored, white-to-off-white, oral granules (95% w/w) in single-dose packets. 4 CONTRAINDICATIONS None. 5 WARNINGS AND PRECAUTIONS None. 3

8 6 ADVERSE REACTIONS 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions and using a wide range of doses, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of VISTOGARD was assessed in 135 patients (median age 59 years, 56% male) treated in 2 single-arm, open-label, multi-center trials. VISTOGARD was administered at 10 grams orally every 6 hours for 20 doses or at a body surface area adjusted dosage of 6.2 grams/m 2 /dose for 20 doses in four patients between 1 and 7 years of age. The median duration of exposure was 4.8 days, with a median of 20 doses (range 1 to 23). VISTOGARD was discontinued for adverse reactions in two (1.4%) patients. Serious adverse reactions and Grade 3 adverse reactions were seen in one patient receiving VISTOGARD (Grade 3 nausea and vomiting). Table 2 summarizes the adverse reactions that occurred in greater than 2% of patients in Studies 1 and 2 combined. Table 2 Adverse Reactions in > 2% of Patients Receiving VISTOGARD in Studies 1 and 2 Adverse Reaction N=135 Patients Vomiting 13 (10%) Nausea 7 (5%) Diarrhea 4 (3%) 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Risk Summary Limited case reports of uridine triacetate use during pregnancy are insufficient to inform a drugassociated risk of birth defects and miscarriage. When administered orally to pregnant rats during the period of organogenesis, uridine triacetate at doses of one-half the maximum recommended human dose (MRHD) of 40 grams per day was not teratogenic and did not produce adverse effects on embryo-fetal development [see Data]. The background risk of major birth defects and miscarriage for the indicated population are unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data In an embryo-fetal development study, uridine triacetate was administered orally to pregnant rats during the period of organogenesis at doses up to 2000 mg/kg per day (about one-half the maximum recommended human dose (MRHD) of 40 grams per day on a body surface area basis). There was no evidence of teratogenicity or harm to the fetus and no effect on maternal body weight and overall health. 4

9 8.2 Lactation Risk Summary There are no data on the presence of uridine triacetate in human milk, the effect on the breastfed infant or the effect on milk production. The development and health benefits of breastfeeding should be considered along with the mother s clinical need for VISTOGARD and any potential adverse effects on the breastfed infant from VISTOGARD or from the underlying maternal condition. 8.4 Pediatric Use The safety and effectiveness of VISTOGARD have been established in pediatric patients. Use of VISTOGARD in pediatric patients is supported by an open-label clinical study of adults (Study 1) and a second open-label clinical study which included 6 pediatric patients ranging in age from 1 to 16 years (Study 2). Four of these pediatric patients were between 1 to 7 years of age and received a body-surface area adjusted dosage of 6.2 grams/m 2 /dose for 20 doses. The clinical response and safety in adult and pediatric patients treated with VISTOGARD were similar; however, clinical data are limited [see Clinical Studies (14)]. 8.5 Geriatric Use Of the 135 patients in clinical studies with VISTOGARD, 30% were 65 and over, including 11% that were 75 and over. Clinical studies of VISTOGARD did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. 11 DESCRIPTION VISTOGARD oral granules contain the active ingredient uridine triacetate which is a pyrimidine analog. The chemical name for uridine triacetate is (2',3',5'-tri-O-acetyl-ß-D-ribofuranosyl)-2,4(1H,3H)- pyrimidinedione. The molecular weight is grams/mole and it has an empirical formula of C 15 H 18 N 2 O 9. The structural formula is: Each single-dose 10 gram packet of VISTOGARD orange-flavored oral granules (95% w/w) contains 10 grams of uridine triacetate and the following inactive ingredients: ethylcellulose (0.309 grams), Opadry Clear [proprietary dispersion of hydroxypropylmethylcellulose and Macrogol] (0.077 grams), and natural orange juice flavor (0.131 grams). 5

10 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Uridine triacetate is an acetylated pro-drug of uridine. Following oral administration, uridine triacetate is deacetylated by nonspecific esterases present throughout the body, yielding uridine in the circulation. Uridine competitively inhibits cell damage and cell death caused by fluorouracil. Fluorouracil is a cytotoxic antimetabolite that interferes with nucleic acid metabolism in normal and cancer cells. Cells anabolize fluorouracil to the cytotoxic intermediates 5-fluoro-2 -deoxyuridine-5 - monophosphate (FdUMP) and 5-fluorouridine triphosphate (FUTP). FdUMP inhibits thymidylate synthase, blocking thymidine synthesis. Thymidine is required for DNA replication and repair. Uridine is not found in DNA. The second source of fluorouracil cytotoxicity is the incorporation of its metabolite, FUTP, into RNA. This incorporation of FUTP into RNA is proportional to systemic fluorouracil exposure. Excess circulating uridine derived from VISTOGARD is converted into uridine triphosphate (UTP), which competes with FUTP for incorporation into RNA Pharmacokinetics Absorption VISTOGARD delivers 4- to 6-fold more uridine into the systemic circulation compared to equimolar doses of uridine itself. Maximum concentrations of uridine in plasma following oral VISTOGARD are generally achieved within 2 to 3 hours, and the half-life ranges from approximately 2 to 2.5 hours. Studies 1 and 2 included an assessment of plasma uridine in a subgroup of patients who were overdosed with fluorouracil or experiencing early-onset of serious fluorouracil toxicities. Samples were obtained prior to VISTOGARD treatment and at 1 to 4 hours following the first and final doses of VISTOGARD given at 10 g (adults) or 6.2 grams/m 2 (pediatric) every 6 hours for up to 20 doses. Plasma uridine concentrations are summarized in Table 3. Table 3 Plasma Uridine Concentrations (µm) in Studies 1 and 2 Study Predose Post First Dose Post Final Dose Study 1 * 8 (33) 99 (64) 160 (81) N = 49 N = 49 N = 40 Study 2 * 5 (17) 119 (59) 153 (68) N = 27 N = 26 N = 24 * Values shown are mean (standard deviation) for plasma uridine (µm) 6

11 Food Effect on Uridine PK: A study in healthy adult subjects receiving a slightly different formulation of uridine triacetate granules (6 gram dose) under fed and fasted conditions showed no difference in the overall rate and extent of uridine exposure. Distribution Circulating uridine is taken up into mammalian cells via specific nucleoside transporters, and also crosses the blood brain barrier. Excretion Uridine can be excreted via the kidneys, but is also metabolized by normal pyrimidine catabolic pathways present in most tissues. Drug Interaction Studies In vitro enzyme inhibition data did not reveal meaningful inhibitory effects of uridine triacetate or uridine on CYP3A4, CYP1A2, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP2E1. In vitro enzyme induction data did not reveal an inducing effect of uridine triacetate or uridine on CYP1A2, CYP2B6, or CYP3A4. In vitro data showed that uridine triacetate was a weak substrate for P-glycoprotein. Uridine triacetate inhibited the transport of a known P-glycoprotein substrate, digoxin, with an IC50 of 344 μm. Due to the potential for high local (gut) concentrations of the drug after dosing, the interaction of VISTOGARD with orally administered P-gp substrate drugs cannot be ruled out. In vivo data in humans are not available. Specific Populations Sex Pharmacokinetics analyses showed that sex did not have a significant effect on uridine pharmacokinetics. Age Pharmacokinetic analysis showed that within the age range evaluated (20 to 83 years), age did not have a significant effect on uridine pharmacokinetics. Body Size Pharmacokinetic analyses showed no clinically meaningful effect of body surface area on uridine PK in adults. 7

12 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies in animals have not been performed to evaluate the carcinogenic potential of uridine triacetate. Uridine triacetate was not genotoxic in the Ames test, the mouse lymphoma assay and the mouse micronucleus test. Orally administered uridine triacetate did not affect fertility or general reproductive performance in male and female rats at doses up to 2000 mg/kg per day (about one-half the maximum recommend human dose (MRHD) of 40 grams per day on a body surface area basis) Animal Toxicology and/or Pharmacology In mice given a sub-lethal dose of fluorouracil, the administration of oral uridine triacetate diminished hematological toxicity as a function of increasing dose, but did not completely prevent hematological toxicity. In mice given a lethal dose of fluorouracil, administration of oral uridine triacetate increased survival to 90% when given within 24 hours. Survival diminished with increasing interval between the fluorouracil dose and uridine triacetate treatment demonstrating that earlier administration of uridine triacetate is more beneficial. In similar experiments in mice, uridine triacetate treatment diminished damage to the intestinal mucosa caused by fluorouracil treatment. 14 CLINICAL STUDIES The efficacy of VISTOGARD was assessed in 135 patients who were treated in two open-label trials, Study 1 (n=60) and Study 2 (n=75). The patients in both studies had either received an overdose of fluorouracil or capecitabine, or presented with severe or life-threatening toxicities within 96 hours following the end of fluorouracil or capecitabine administration. Overdose was defined as administration of fluorouracil at a dose, or infusion rate, greater than the intended dose or maximum tolerated dose for the patient s intended regimen of fluorouracil. VISTOGARD was administered at 10 grams orally every 6 hours for 20 doses or at a body surface area adjusted dosage of 6.2 grams/m 2 /dose for 20 doses for four patients between 1 and 7 years of age. The major efficacy outcome was survival at 30 days or until the resumption of chemotherapy if prior to 30 days. In Study 1 and Study 2 combined, the median age of the patients was 59 years (range: 1 to 83), 56% were male, 72% were white, 9% were Black/African American, 6% were Hispanic, 4% were Asian, and 95% had a cancer diagnosis. Of the 135 patients, 117 were treated with VISTOGARD following an overdose of fluorouracil (n=112) or capecitabine (n=5), and 18 were treated after exhibiting severe or life-threatening fluorouracil toxicities within 96 hours following the end of fluorouracil administration. The severe or life-threatening toxicities involved the central nervous system (such as encephalopathy, acute mental status change), cardiovascular system, gastrointestinal system (such as mucositis), and bone marrow. A total of six pediatric patients were administered VISTOGARD. Four patients initiated 8

13 VISTOGARD more than 96 hours following the end of fluorouracil or capecitabine administration. Of the 112 patients overdosed with fluorouracil, 105 (94%) were overdosed by infusion rate only (range 1.3 to 720 times the planned infusion rate), four (4%) were overdosed by dose only, and three (3%) were overdosed by both dose and rate. The survival results are shown in Table 4. Of the 135 patients who were treated with VISTOGARD in Studies 1 and 2 there were five deaths due to fluorouracil or capecitabine toxicity (4%). Of the five patients who died, two were treated after 96 hours following the end of fluorouracil administration. In the patients treated with VISTOGARD for an overdose of fluorouracil or capecitabine in Studies 1 and 2 combined (n=117), survival at 30 days was 97% (n=114). In the patients receiving VISTOGARD for early-onset severe or life-threatening toxicity in Studies 1 and 2 combined (n=18), the survival at 30 days was 89% (n=16). In these studies 33% of patients (n=45) resumed chemotherapy in less than 30 days. Based on retrospective historical case reports of 25 patients who were overdosed with fluorouracil and received supportive care only, all were overdosed by rate with a range 1.9 to 64 times the planned infusion rate, and 84% died. Table 4 Combined Efficacy: All Patients in Study 1 and Study 2 Overdose Early-Onset Overall Total Enrolled Survival a 114 (97%) 16 (89%) 130 (96%) Death 3 (3%) 2 (11%) 5 (4%) a Survival includes patients who survived at 30 days or patients who resumed chemotherapy prior to 30 days. 16 HOW SUPPLIED/STORAGE AND HANDLING VISTOGARD orange-flavored oral granules (95% w/w) are available in single-dose packets containing 10 grams of uridine triacetate. NDC Number Package Configuration Course of therapy package: 1 carton containing 20 single-dose packets of VISTOGARD Hour Pack: 1 carton containing 4 single-dose packets of VISTOGARD Store at USP controlled room temperature, 25 C (77 F); excursions permitted to 15 to 30 C (59 to 86 F). 9

14 17 PATIENT COUNSELING INFORMATION Advise the patient or caregiver to read the FDA-approved patient labeling (Patient Information) Dosing Instructions [see Dosage and Administration (2.1) and (2.2)] Advise the patient or caregiver: The importance of taking all 20 doses, even if they feel well. That VISTOGARD can be taken mixed in food (applesauce, pudding or yogurt). That the VISTOGARD granules should not be chewed. That if the patient vomits within 2 hours of taking a dose of VISTOGARD to take another complete dose as soon as possible after vomiting. Take the next dose at the regularly scheduled time. That if the patient misses a dose at the scheduled time, to take that dose of VISTOGARD as soon as possible. Then take the next dose at the regularly scheduled time. Manufactured for and distributed by: Wellstat Therapeutics Corporation Rockville, MD VISTOGARD is a registered trademark of Wellstat Therapeutics Corporation. The Wellstat logo is a registered trademark of Wellstat Therapeutics Corporation. 2015, 2018 Wellstat Therapeutics Corporation. All rights reserved. 10

15 Patient Information VISTOGARD (VIS-toe-gard) (uridine triacetate) oral granules What is VISTOGARD? VISTOGARD is a prescription medicine that contains uridine, a substance that is normally found in your body. VISTOGARD is used for emergency treatment of adults and children: after an overdose of fluorouracil or capecitabine with or without symptoms, or who have early signs of severe or life-threatening side effects that affect the heart, or early signs of severe or life threatening neurologic (central nervous system) problems, or certain unusually severe side effects within 4 days (96 hours) after receiving treatment with fluorouracil or capecitabine VISTOGARD should only be used for the emergency treatment of side effects of fluorouracil or capecitabine, because it may decrease the effectiveness of these medicines. It is not known if VISTOGARD is safe and effective if started more than 4 days (96 hours) after the end of a dose of fluorouracil or capecitabine. Before taking VISTOGARD, tell your healthcare provider about all your medical conditions, including if you: are pregnant or plan to become pregnant. It is not known if VISTOGARD will harm your unborn baby. are breastfeeding or plan to breastfeed. It is not known if VISTOGARD passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby if you take VISTOGARD. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. How should I take VISTOGARD? Take VISTOGARD exactly as prescribed by your healthcare provider. It is important that you take all 20 doses of VISTOGARD even if you feel well. VISTOGARD comes in single-dose packets that contain 10 grams of orange-flavored granules. If your healthcare provider decides that you can give VISTOGARD to your child at home, it is important that you follow your healthcare provider s instructions. Your healthcare provider will prescribe VISTOGARD to your child based on your child s weight. The usual adult dose of VISTOGARD is 1 packet taken by mouth every 6 hours for a total of 20 doses. If you vomit within 2 hours of taking a dose of VISTOGARD, take another full dose as soon as possible. Then take your next VISTOGARD dose at your next regularly scheduled time. If you miss a dose of VISTOGARD at the scheduled time, take the missed dose as soon as possible. Then take the next dose at the regularly scheduled time. Preparing and taking a dose of VISTOGARD: Mix each packet of VISTOGARD granules with 3 to 4 ounces of soft food such as applesauce, pudding or yogurt in a small container. Take all of the VISTOGARD granules mixed with food within 30 minutes of mixing. Do not chew the VISTOGARD granules. Drink at least 4 ounces of water to make sure that you swallow all of the medicine. What are the possible side effects of VISTOGARD? Common side effects of VISTOGARD include: vomiting, nausea, and diarrhea. These are not all the possible side effects of VISTOGARD. Call your doctor for medical advice about side effects. You may report side effects to FDA at FDA

16 How should I store VISTOGARD? Store VISTOGARD at room temperature between 68 F to 77 F (20 C to 25 C) Keep VISTOGARD and all medicines out of the reach of children. General information about the safe and effective use of VISTOGARD. Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use VISTOGARD for a condition for which it was not prescribed. Do not give VISTOGARD to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about VISTOGARD that is written for health professionals. What are the ingredients of VISTOGARD? Active Ingredient: uridine triacetate Inactive Ingredients: ethylcellulose, Opadry Clear [proprietary dispersion of hydroxypropylmethylcellulose and Macrogol], and natural orange juice flavor. Manufactured for and distributed by Wellstat Therapeutics Corporation, Rockville, MD VISTOGARD is a registered trademark of Wellstat Therapeutics Corporation. The Wellstat logo is a registered trademark of Wellstat Therapeutics Corporation. 2015, 2018 Wellstat Therapeutics Corporation. All rights reserved. For more information, go to or call This Patient Information has been approved by the U.S. Food and Drug Administration Issued: 12/